Possible directions of increasing efficiency of Healthcare system in the Republic of Serbia Possible Directions for Increasing Efficiency of Healthcare System in Serbia Contents Disclaimer .............................................................................................................................1 Abbreviations .......................................................................................................................2 I Executive Summary ...........................................................................................................3 1.1 Purpose and main objectives of the Document .............................................................3 1.2 Key findings and recommendations ..............................................................................5 MACRO HEALTHCARE STUDY………………………………………………………………….10 II Macroeconomic and Health Spending indicators in Serbia .........................................11 2.1 Macroeconomic environment ......................................................................................11 2.2 Serbian Health Profile .................................................................................................14 2.2.1 Basic indicators and top causes of death ..............................................................14 2.2.2 Serbian pharmaceutical and medical device markets ...........................................18 2.2.3 Procurement of medicines and medical supplies in public healthcare ...................19 2.2.4 Innovative pharmaceutical products in Serbia ......................................................22 2.3 Overview of the Healthcare Spending in Serbia ..........................................................26 2.3.1 Waiting lists ..........................................................................................................31 III Public Health System Funding Value Chain .................................................................33 3.1 General overview of Serbian healthcare system financing ......................................33 3.3 Intermediary institutions..........................................................................................39 3.3.1 Republic Health Insurance Fund ...........................................................................39 3.3.2 Pension and Disability Insurance Fund (PDIF) .....................................................44 3.3.3 Military Social Insurance Fund (MSIF) ..................................................................46 3.4. Public Healthcare providers .......................................................................................47 3.4.1 Basic performance indicators and financial business results ................................47 3.4.2 Regular Income and Income From Sale of Non/Financial Assets .........................48 3.4.3 Current Expenditures and Expenditures for Procurement of Non-Financial Assets ......................................................................................................................................49 3.4.4 Expenditures for employees .................................................................................50 IV Public Health System Financial Sustainability High Level Assessment ....................51 4.1 Assessment of sustainability ..................................................................................51 4.2 Analysis of relationships between stakeholders in healthcare system in Republic of Serbia 53 4.2.1 Health insurance contributions and Republic Health Insurance Fund ..............53 4.2.2 Contributions and Pension and Disability Insurance Fund ...............................55 4.2.3 Republic Health Insurance Fund and Pension and Disability Insurance Fund .......56 4.2.4 Donations and Republic Health Insurance Fund ...................................................56 4.2.5 Republic Health Insurance Fund and public healthcare institutions ......................57 4.2.6 Health insurance contributions and Military Social Insurance Fund (MSIF) ...........62 4.2.7 Military Social Insurance Fund and Public military healthcare institutions .............63 All rights reserved – Ernst & Young d.o.o. Beograd – A member firm of Ernst & Young Global Limited Possible Directions for Increasing Efficiency of Healthcare System in Serbia 4.2.8 Individuals to private insurance fund .....................................................................63 4.2.9 Private insurance fund to private/public healthcare institutions .............................63 V Financial Reporting and Controlling in Serbian Public Healthcare System ...............65 5.1 Financial reporting ......................................................................................................65 5.2 Financial controlling ....................................................................................................66 5.2.1 Role of Ministry of Health......................................................................................69 VI Private Healthcare Overview in Serbia .........................................................................70 6.1 Participation of public and private healthcare in the overall health system of Serbia 70 6.2 Assessment of out of pocket payments in the health system ..................................73 6.3 Comparison of Serbian Healthcare System With World's Best Practice..................77 6.3.1 General Overview of World’s Best Practices in the Domain of Healthcare ............77 6.3.2 EHCI – Euro Health Consumer Index ...................................................................80 6.3.3 Diagnosis-Related Groups – DRGs ......................................................................81 6.4 Role of private insurance companies and impact of voluntary health insurance in Serbian healthcare ............................................................................................................83 6.4.1 Health insurance in Serbia – General overview ....................................................83 6.4.2 Voluntary Health Insurance – Market Insight ........................................................84 6.4.3 Voluntary Health Insurance inside the Republic Health Insurance Fund ...............87 VII Information systems in Serbian healthcare institutions ............................................89 7.1. Public sector ..............................................................................................................89 7.2. Private sector .............................................................................................................91 MICRO HEALTHCARE STUDY ...........................................................................................92 VIII Comparative view of expenses, incomes and costs of selected services ...............93 8.1 Observed services ..................................................................................................93 8.2 Primary care ...........................................................................................................95 8.2.1 Analysis of direct costs per selected service between public and private institutions ......................................................................................................................................95 8.2.2 Analysis of direct costs per selected service between public and private institutions – „WHAT - IF Scenario“ ...............................................................................97 8.2.3 Analysis of incomes between public and private institutions in primary level of care 98 8.2.4 Analysis of expenses between public and private institutions in primary level of care 100 8.3 Secondary/tertiary care ........................................................................................ 102 8.3.1 Analysis of incomes in public and private institutions in secondary/tertiary level of care ............................................................................................................................. 105 8.3.2 Analysis of expenses between public and private institutions in secondary/tertiary level of care ................................................................................................................. 106 RECOMMENDATIONS ...................................................................................................... 108 All rights reserved – Ernst & Young d.o.o. Beograd – A member firm of Ernst & Young Global Limited Possible Directions for Increasing Efficiency of Healthcare System in Serbia IX Recommendations for Increasing Serbian Healthcare System Efficiency ............... 109 9.1 Financial sustainability of the system ........................................................................ 109 9.2 Inclusion of private healthcare providers in the system ............................................. 116 9.3 Prevention and innovative medicines ........................................................................ 121 9.4 Reduction of waiting lists ........................................................................................... 122 9.5 Centralization or Decentralization?............................................................................ 125 9.6 IT Support ................................................................................................................. 128 9.7 Voluntary Health Insurance ....................................................................................... 131 X Review of regulatory changes and measures necessary for system improvement .